NURSING CARE PLAN

(NCP)
NURSING CARE PLAN Document QF-CN-25 Revision 1
Code Number
(NCP)
Effectivity August 17, 2018

NAME/ INITIALS OF PATIENT:_A.B.C.___________________________________________ AGE:_23_________ SEX: _F_________ STATUS: MARRIED______

ADDRESS: ________________________________________________________________ HOSPITAL: BGHMC__________________ WARD: OBgyne______
PRINCIPAL MEDICAL DIAGNOSIS: ___________________________________________________________________________________________________
NURSING CARE PLAN DEVSED BY:_ENRIQUEZ, Angelique Jade_________________________ YEAR AND SECTION: III C__________ GROUP_14___________
SCORING IMPLEMENTATION
CRITERIA VL L H VH
NURSING ORDERS / APPROACHES RATIONALE
Content
- Insertion of indwelling Folley Catheter (IFC) as needed. - This will provide an accurate measurement of the renal status and perfusion
Complete
with regards to fluid volume. Note: Pressure on the urethra may obstruct urine
Assessment
Parameters flow/cause bladder distention if vaginal packs are inserted.
Nursing
Diagnosis
Short-term
Outcome
Long-term
Outcome
Nursing
Orders
Rationales
Actual
outcome
TOTAL SCORE

VH – Very High
H – High
L – Low
VL – Very Low

Rated by:

Date:
__________________

Conforme:
ACTUAL OUTCOME DATE AND TIME RESOLVED
Enriquez, Angelique Jade
Date:________________
 NURSING CARE PLAN Document QF-CN-25 Revision 1
(NCP) Code Number
Effectivity August 17, 2018
DATE AND TIME NURSING DIAGNOSIS SHORT – TERM AND LONG – TERM OUTCOMES
Deficient Fluid Volume related to Excessive blood loss after Patient will have a lochia flow of less than Patient will demonstrate improvement
dilatation and curettage one saturated perineal pad per hour. in the fluid balance.

ASSESSMET PARAMETERS IMPLEMENTATION

NURSING ORDERS / APPROACHES RATIONALE
- Assess and record the type, amount, and site of the bleeding; Count - The amount of blood loss and the presence of blood clots will help to
and weigh perineal pads. determine the appropriate replacement need of the patient.

Subjective:
 “nagsakit, pirmi. Nag adu
rumrumwar nga dara.”
 Used 3 saturated perineal pads
per hour.
Objective:
 Cyanosis on the lips
 Blood pressure of: 90/60mmHg
 Delayed capillary refill
 Dry skin/mucous membrane
 SPO2 of 89%
- Assess the location of the uterus and degree of the contractility of
the uterus/ Massage boggy uterus using one hand and place the second
hand above the symphysis pubis.
- Monitor vital signs including systolic and diastolic blood pressure,
pulse and heart rate. Check for the capillary refill and observe nail beds
and mucous membranes.
- Note for the presence of vulvar hematoma and apply an ice pack if
indicated.
- Measure a 24-hour intake and output. Observe for signs of voiding
difficulty.
- Observe for reports of persistent perineal pain or feeling of vaginal
fullness. Apply counterpressure on labial or perineal lacerations.
- The degree of the contractility of the uterus will measure the status of
the blood loss. Placing one hand just above the symphysis pubis will
prevent possible uterine inversion during a massage.
- Increased heart rate, low blood pressure, cyanosis, delayed capillary
refill indicates hypovolemia and impending shock. Decrease fluid
volume of 30-50% will reflect changes in the blood pressure.
- Small hematoma can be managed by an ice pack and rest.
- This will help in determining the fluid loss. A urine output of 30-50
ml/hr or more indicates an adequate circulating volume.
Hematomas often result from continued bleeding from laceration of
the birth canal.

- Maintain a bed rest with an elevation of the legs by 20-30° and trunk The position increases venous return, making sure a greater availability
horizontal. of blood to the brain and other vital organs. Bleeding may be decreased
with the bed rest.

- Monitor Hematocrit and Hemoglobin levels. Hgb and Hct determine the amount of blood loss. Each milliliter of
blood carries 0.5 mg of hemoglobin.
ACTUAL OUTCOME DATE AND TIME RESOLVED